Navigating the Health Insurance Maze

22/04/2016
Agenda
Everyone needs to have insurance, but it is no
longer a “one size fits all system”. We will
provide an general overview of insurance as well
as things you may want to consider
o How has the Affordable Care Act
(ACA) impacted health care?
o Requirements for Health Insurance
o Types of Insurance Coverage
o Considerations when choosing a Plan
o Common Road Blocks – Networks and
Care Costs
Navigating the Health Insurance Maze
o Government insurance programs
o Interactive resources
Strategies to Effectively Manage Insurance Systems
Brendan Bietry, Case Manager – Clinical Team
P: 800.532.5274
421 Butler Farm Road
Hampton, VA 23666
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P: 800.532.5274
www.patientadvocate.org/gethelp
www.patientadvocate.org/gethelp
|
P: 800.532.5274
www.patientadvocate.org/gethelp
Affordable Care Act
What Does PAF Do?
•
Foundation seeks to safeguard
patients through effective
mediation assuring access to
care, maintenance of
employment and preservation of
their financial stability.
• Assigned Case Manager
• Short-term case duration
• “Active liaisons” that work on
behalf of patient
• Phone-based interaction
•
Includes coverage of routine care costs for approved
clinical trials
•
No more lifetime or annual limits on coverage for
essential services
caregivers, providers
•
• Confidential and Security-aware
• Engagement within 48 hours
• Issues are focused around Insurance
| Financial Stability & Medical Debt |
Employment Related
Coverage of preventive services at no out-of-pocket
cost
•
10 categories of Essential Health Benefits coverage
•
You have the right to appeal a health insurance
company’s decision to deny payment of a claim
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Clinical Trial Coverage Mandate
 Federal provision does not preempt the (35) states with existing clinical trial
coverage standards in place - establishes a universal, minimum rule.
Health plans or issuers cannot deny participation in an approved trial
Costs for routine care consistent with plan coverage ARE COVERED
 Plan will require trial participation through a NETWORK Provider
Patients are still responsible for co-payments, deductibles, and travel costs
Trial sponsors: Pharma./Tech. Companies, NCI/NIH/DOD/CMS (.gov trials)
Medicare covers routine costs of qualifying clinical trials – (including
reasonable/necessary services used to diagnose and treat complications)
 Medicaid: ACA does not apply to state Medicaid coverage for clinical trials
P: 800.532.5274
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Cannot be charged higher premiums due to health
status or gender (but can for smoking-use and age)
•
• Free assistance to patients,
P: 800.532.5274
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Cannot be denied coverage due to pre-existing
conditions
MISSION: Patient Advocate
• Personalized assistance
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**Grandfathered plans still in existence
may not have to follow all ACA rules and
provisions.
Be cautious and know the specifics if you
are a new enrollee into a grandfathered
plan. Ask if your plan is “grandfathered’.
P: 800.532.5274
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Qualified Health Plans
Insurance that ‘counts’ as acceptable
 Any plan purchased on the Marketplace
 Retiree plans
 COBRA coverage
 Medicare part A or C, or Advantage
 CHIPs plans for children
 most Medicaid plans
 TRICARE
 Comprehensive group coverage through employer
 Grandfathered plans
Insurance plans that do NOT count as coverage
Vision or Dental policies
Workers' compensation
Coverage only for a specific disease or condition
Plans that offer only discounts or cash payments to
reimburse a certain defined list of services
Catastrophic coverage (except for <30yoa)
Insurance must be active
for at least 10 months out
of the year to avoid
penalty.
If you’re uninsured for
just part of the year, 1/12
of the yearly penalty
applies to each month
you’re uninsured.
P: 800.532.5274
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22/04/2016
Insurance Marketplace
Essential Health Benefits
Allows consumers to research and compare plans
directly
Only place for financial assistance to
help pay for insurance
One-stop shopping for those looking to enroll in plans
or those that may be eligible for Medicaid or CHIPs
• Premium subsidies (Tax credits)
for 100%-400% FPL
• Cost-Sharing Assistance for
100%-250% FPL
• Must be enrolled in Silver or
higher level plan
• May have to repay if financial
situation improves without
adjustment to credit amount
Plans are grouped by category to help sort options,
called Bronze, Silver, Gold, Platinum
If your family is enrolling in a marketplace planeveryone does not have to enroll into the same plan.
Can be individually based.
www.healthcare.gov
NOT for those who are enrolled in Medicare or
Medicare-eligible
**Grandfathered plans still in existence may
You have the right to appeal a decision from the
marketplace (ex: decision on financial assistance,
eligibility for Medicaid, penalty exemption)
not have to follow all ACA rules and provisions,
including offering the Essential Health Benefits.
P: 800.532.5274
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Enrollment Basics
 Enrollment time periods vary but should be defined
and publically available
Marketplace – Late Fall of each year
Employer Based – ex) July of each year
Medicare – October – Dec of each year
 Know the Enrollment Date compared to the
Effective Date of plan policy
 You commit to monthly premiums for the entire
plan year.
 You may have multiple eligibility options and
arrangements to enroll under. Consider and
compare costs for different options.
 Open enrollment allows the opportunity to look
inside the plan details before committing.
Special Enrollment
The window of time following a life event
that allows you the opportunity to enroll or
switch plans.
Examples:
• Getting married or divorced
• Having or adopting a baby
• Loss of employer based coverage
• Turning 26 and loosing coverage under
parent's plan
• Loosing eligibility for Medicaid or CHIPS
• Changes in citizenship
• Leaving incarceration
• New employee at workplace
Voluntarily dropping coverage before
the plan year ends, and/or nonpayment
does not qualify
P: 800.532.5274
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P: 800.532.5274
www.patientadvocate.org/gethelp
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Direct Enrollment with
Insurance Company
•
Many insurance companies are also
matching Marketplace open enrollment
period in the fall with limited enrollment
at other times
•
You can compare and research among
that Insurer’s products only
•
May be able to offer you Marketplace
plans and other non-marketplace plans in
their portfolio
•
Web brokers: getinsured.com,
healthsherpa.com, ehealth.com,
gohealth.com
If you enroll during special enrollment, you
may end up with a partial plan year, until
the following open enrollment.
P: 800.532.5274
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Calculating the Fee
Am I Required to Have
Health Insurance?
Affordable Care Act
If you can afford health insurance but choose not to buy it, you
Fees are calculated and assessed
must pay a fee or have a health coverage exemption.
with your annual taxes the following
The fee is calculated for each uninsured individual, kids
year.
If you don’t have coverage in 2016, you’ll pay
the higher of these two amounts:
2.5% of your yearly household income.
Only the amount of income above the tax filing
threshold, (about $10,150 for an individual), is
used to calculate the penalty.
included.
Requirement is for a “qualifying” plan with “minimum essential
coverage” to ensure comprehensive coverage
$695 per person for the year ($347.50 per
child under 18). The maximum penalty per
family using this method is $2,085.
The fee is sometimes called the "penalty," "fine," "individual
responsibility payment," or "individual mandate.“
Exemptions from the Fee
•
•
•
•
•
Income-related exemptions
Health Coverage-related exemptions
Group membership Exemptions
Hardship Exemptions
Other exemptions
Fees are calculated and assessed with your
annual taxes
If you pay the fee, you are still uninsured and must pay 100%
of your healthcare costs.
Example: If your annual income is $35,000 a year and
do not have coverage, you will be responsible for $695
penalty
The maximum penalty is the national average premium for a
Bronze plan.
P: 800.532.5274
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P: 800.532.5274
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22/04/2016
Choosing a Plan
Financial Challenges
Read the Plan Summary:
• Compare cost-sharing elements
(co-pays, co-insurance, deductibles, out-of-pocket max)
• Review Non-Covered Benefits or Exclusions
• Perform sample calculations for various scenarios
• Know the difference in plan types (HMO, PPO, etc.)
• Understand your “typical” medical needs
Those diagnosed with chronic conditions frequently
have challenges balancing financial obligations
Medical Visits & Care
Tests, Laboratory, Radiology
Medication Costs
Monthly Premium
Over-the-counter needs
Medical equipment
Food & nutrition
Prescription coverage:
• May need you to research on Insurer’s website
• List of covered drugs (“formulary”)
• Prescription tiers – medications are assigned to a
category based on drug usage, cost and clinical
effectiveness
• Specialty drug tiers – the highest drug category,
typically with the highest copayment or coinsurance
amount
• Review network pharmacy and/or mail pharmacy
options
Combined with:
Decreased income due to time away from work
P: 800.532.5274
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Cost Comparison:
**Keep in mind that your annual total cost of care
goes beyond the monthly premium
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Insurance Networks
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Insurance Plan Transitions
When:
Insurance plans vary in terms of network and
covered services.
•
•
•
•
•
Be proactive to avoid future
challenges with insurance
plan details.
Providers
Specialists
Facilities
Diagnostics / Labs / Radiology
Pharmacy
Network is constantly changing, provider
• Your plan is ending its plan term
• Your employer-based plan is ceasing
• You are researching plan options and looking to
transition to a new plan
• Your eligibility for Medicaid/Medicare is changing
• You no longer meet coverage under family plan
as dependent
• You have a life event affecting your insurance
(marriage, divorce)
Treatment may be
long-term, so review
insurance plan options each
open enrollment period….
…..even if you have been
happy with your insurance.
Why?
Better reimbursement for treatment
Better reimbursement for medications
Different network of providers
Lower out of pocket costs / deductibles
Health Savings Accounts / Flexible Savings Plans
relationships with insurer occur regularly
with limited notice
Plans may have limited or no Out-of-Network
coverage
P: 800.532.5274
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Plan Vocabulary to Know During Enrollment
What can you do?
Dealing with Your
Insurance Network
• Become familiar with insurancespecific terminology (co-payment,
deductible, etc.)
P: 800.532.5274
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• Look for plan with out-of-network
coverage in future
• Know your insurance plan
language.
• Be familiar with insurance
paperwork formats like EOBs,
claims, prior authorizations, etc.
• Always check if your provider,
facility or lab work is in-network
beforehand.
• Appeal if needed to treat out-ofnetwork provider with in-network
rates
• Obtain needed referrals if
necessary
• Call Insurer if any questions
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
Premium – the amount that must be paid for your health plan benefits to be active.
Usually paid monthly.

Out-of-pocket costs – Your expenses for medical care that aren't reimbursed by
insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments
for covered services plus all costs for services that aren't covered.

Out-of-pocket maximum/limit – the most you could pay during a plan year for
covered service

Deductible- the amount you owe for health services before your plan begins to pay.
During this period you pay 100% of all costs for care that is received.

Copayment – a defined fixed amount you pay for covered health care services, for
example $15 for office visit. This amount can vary by type of covered service

Coinsurance – your share of the cost of a covered health service, calculated as a
percent of the allowed amount

Formulary – a list of approved drugs covered by a prescription drug program
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22/04/2016
Example Comparison – Drug Plans
Example Comparison
Molina Marketplace Gold HMO
Aetna Silver POS
$251/ month
$281 / month
$1000
$3,000
Monthly Premium
Deductible
Out of Pocket Maximum
$6,850
$4,900
Primary Care Visit
Specialist Visit
Molina Marketplace Gold HMO
Aetna Silver POS
$5
$10
$50/20% co-insurance
$40/$70
20% co-insurance
50% co-insurance
Included in plan’s out-of-pocket
maximum; $0 deductible
Included in plan’s out-of-pocket
maximum; *$500 deductible*
Prescription Drugs - Generic
$15
$5
$35 In-Network,
Not covered Out-ofNetwork
$55 In-Network,
50% Out-of-Network
Prescription Drugs – Preferred and
Non-preferred Brand
Prescription Drugs - Specialty
Drugs
30% co-insurance
20% co-insurance after
Outpatient facility fee deductible; No out of after deductible; 50%
out of network
network benefit
Prescription Drugs Out-of-Pocket
Maximum *some plans have separate
Prescription Drug Deductibles*
**These plans specifics and figures are fictional and only for example purposes.
P: 800.532.5274
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Why are Specialty Drugs
Challenging?
Not a ”typical prescription” experience ---
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Insurance Tiers
Some plans are
implementing a 5th Tier
or “Specialty Tier”
Can
be %
of
drug
total
cost
• Special handling, administration or
monitoring
• Terminology, process, reimbursement
--------------------------------Updated yearly, although
subject to change at any
point. Medications may be
reclassified to a new tier, or
dropped all together from
formulary.
Paid Upfront Before
Access
------------------------------------Patient may also have drug
benefit-specific deductible to pay
before insurance coverage
begins. All pharmacies require
total payment upfront before
dispensing or releasing
medication to patient.
Noncompliant
with treatment
Co-payments and
Co-insurances are not linear
and may grow substantially
with tier level.
-----------------------Cost concerns can
push patients to not
fill a prescription, skip
pills, or otherwise not
take as prescribed
without doctor
awareness. This may
impact their care and
overall health.
• Limited distribution sites
• Prior authorization required;
increasing number not covered
• Higher patient financial responsibility
Prior-Authorizations
---------------------------------For higher tier medications,
insurers require the patient to
go through a priorauthorization process to access
medication.
• For chronic or difficult health
conditions
P: 800.532.5274
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P: 800.532.5274
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Insurance Appeals
Step Therapy
--------------------------------------Even if medication is ‘covered’ under
plan’s tier, you and your doctor may be
required to attempt other medications
first or provide documentation as to why
this is not feasible.
P: 800.532.5274
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P: 800.532.5274
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Preparing Your Appeal
Identifying the Reason for the Denial
• Letter of medical rationale/necessity from
• Services are deemed not medically
necessary
your treating provider
• Chart Notes from your treating physician
(outlining failed alternatives or effectiveness of
service in question)
• Services are no longer appropriate in
specific health care setting or level of care
• Services are considered experimental/
investigational for this condition (off-label
use of prescribed therapy)
•
Results of any relevant tests or procedures
• Current peer-reviewed literature, studies,
clinical trial data from your doctor or wellrecognized journals (documenting the medical
effectiveness of the requested services)
• Clinical effectiveness of the procedure
or therapy has not been proven
• Your own personal narrative or the narrative
of an authorized representative describing the
need for the requested service
• Not eligible for the benefit requested
under your health plan (Pre-authorization
criteria not met)
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22/04/2016
Employer-based Plans
Medicare
Part A (Hospital Insurance)
Many employers will cover a portion of the monthly
premiums on behalf of employee (not always for
family or dependents)
•
May have workplace requirements for eligibility
(ex: hours worked each week)
•
Part B (Outpatient Insurance)
Other benefits may go along with health plan options
including
•
•
•
•
•
Health Savings Accounts along with High Deductible Plans
Flexible Spending Accounts / Cafeteria Plans
Supplemental Plans – ex) Accident or Cancer Plans
Vision Plans & Dental Plans
*additional premiums for supplemental plans
If you decline employers insurance, you may not be
eligible for financial assistance through the
Marketplace
Mid-size to large businesses are
mandated to provide health
coverage for employees – can
utilize the SHOP Marketplace for
their plan selection
P: 800.532.5274
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•
You automatically qualify for Extra Help if:
• You have full Medicaid coverage
• You receive Supplemental Security
Income (SSI)
• You get help from Medicaid paying your
• Drug Utilization Rules
Medicare premiums
DEDUCTIBLE : BENEFICIARY
PAYS
$360
CO-INSURANCE AMOUNT : PAYS 25%
COSTS FROM $361-$3310
OF
DONUT HOLE/COVERAGE GAP - PAYS 100%
OF COSTS FROM $3311-$7062
CATASTROPHIC: 5%
•
May provide receive benefits not covered by
Medicare, e.g. emergency health care outside
the U.S.
•
You must have Medicare Part A & Part B to be
eligible for a Medigap plan
•
10 plan options (A,B,C,D,F*,G,K,L,M,N) with
Plan F offering all 9 Medigap benefits
•
27 states required to offer at least one plan
option for disabled Medicare eligible
individuals under 65
All others must apply:
•
•
www.medicare.gov
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Medicare Savings Programs
Qualified Medicare Beneficiary (QMB)
$1010 (single)
$1355 (married )
Specified Low-Income Beneficiary
$1208 (single)
$1622 (married)
Qualified Individual (QI)
$1357 (single)
$1823 (married)
*Resource limits are $7,280/$10,930 *
Qualified Disabled and Working
Individuals (QDWI)
Income limits are set at 200% of FPL
($1,980 for individual)
Online at www.socialsecurity.gov
Call SSA at 1-800-772-1213
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Medicare Supplemental
Plans (Medigap)
Sold by private insurance companies to pay
"gaps" in coverage
•
•
•
Life circumstances may allow you to
make changes to Medicare
Advantage/ or drug coverage
Moving in or out of current plan area
Losing other coverage
Option to enroll in other coverage as
good as Medicare
Becoming eligible for Extra Help –
continuous special enrollment
You enter, live in or leave a longterm care facility
REMAINDER OF YEAR
P: 800.532.5274
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•
Part D (Prescription Drug)
• Prescription drug coverage
• Compare Medicare Advantage and Part D
stand-alone plans www.q1medicare.com
•
Qualifying for Extra Help
Part D covers oral or other selfadministered drugs, certain vaccines
Prior authorization: Medical Necessity
Quantity/Dosage limits
Step therapy: Requires trial of lower
cost alternatives before the plan will
cover the prescribed drug.
• Plans have process in place to
request exceptions to formulary
Part C (Medicare Advantage)
• Combines Part A & B and may include Part D
• Managed by private insurance companies
• Different copayments, coinsurance or
deductibles
Special Enrollment Circumstances
P: 800.532.5274
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Part B covers outpatient injectable
and infusion drugs administered as
part of a physician service
•
•
•
Covers doctor visits, some preventative
services, diagnostic tests and durable
medical equipment
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Medicare Drug Coverage
•
Pays for inpatient hospital stays, skilled
nursing care, home health and hospice care
P: 800.532.5274
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Medicaid
Medicaid is state-run insurance that provides
medical assistance for people with limited income
and resources
(Not a cash support program; pays medical providers directly for care)
Guaranteed issue for Medigap
supplemental plans is the 7 month
period when you initially become
eligible for Medicare
P: 800.532.5274
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You can apply:
• Through the Insurance Marketplace and it will screen you for
Medicaid eligibility
• Directly with local Medicaid offices in your area
• Enrollment can take place at any time during the year
• You may loose eligibility at any time during the year based
on changes in income
Medicaid plan types differ between states:
You may have an HMO plan, Spend-down plan or different type of plan
P: 800.532.5274
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22/04/2016
State Decisions on Medicaid Expansion
Children’s Health Insurance
Program (CHIP)
•
•
•
•
•
Children and teens up to age 18
Young people up to 21 may be covered under
Medicaid
Youth who have “aged out” of foster care can
be covered under Medicaid until they reach
age 26
Eligibility depends on income, number of
people in the family and rules in each state.
Preventive services for children are available
at no cost.
To apply:
• InsureKidsNow.gov
• 1-877-543-7669
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After Enrollment
 You should receive a confirmation of effective plan dates
following enrollment
 Ability to gain electronic access to insurer’s website, with
more details of plan and provider network, formulary, copy
of policy numbers
 Look out for a welcome packet with plan summary, insurance cards
 You will begin to see premium invoices connected to payment details.
Make your payment promptly to ensure effective coverage!
 If receiving financial assistance, you will get a statement for tax purposes
If you do not receive these things, follow up immediately to ensure
enrollment was completed and processed accurately!
P: 800.532.5274
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Co-Pay Relief Program

(MDS fund is currently OPEN!)
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P: 800.532.5274
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Get Organized
• Develop a filing system to compare
Explanation Of Benefits(EOBs)/bill invoices
• Make a household budget
• Track deductibles
• Estimate out of pocket costs for anticipated
services - utilize cost calculators!
 www.healthcarebluebook.com
 www.fairhealthconsumer.org
• Record notes of all interactions with insurer
and billing contacts – keep a chronology of
Dates of Service (DOS)
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My Resource Search Mobile Phone App
Medication Assistance
Programs

P: 800.532.5274
www.patientadvocate.org/gethelp
www.copays.org

Patient Access Network www.panfoundation.org

Chronic Disease Fund www.gooddaysfromcdf.org
MDS/Myeloproliferative Disease

Healthwell Foundation
(MDS fund is closed)

The Leukemia and Lymphoma Society www.lls.org
National Org. Rare Disorders www.rarediseases.org

Alexion (eculizumab) www.alexion.com/patients/support

Thymoglobulin ATG www.sanofipatientconnection.com

Celgene: www.celgenepatientsupport.com
(MDS Fund is open)
www.healthwellfoundation.org
www.patientadvocate.org/myresources
Or from APP STORE directly from your phone
My Resources
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22/04/2016
Coverage Access Guide App
Coverage Access Guide: A Consumer’s Guide
to Insurance is designed to answer frequently
asked questions about accessing, enrolling and
maintaining healthcare coverage.
Download Now and
Access Additional Tips
During Presentation
FREE, user-friendly, article-based educational
guide geared to help current and future patients
overcome common healthcare obstacles in order
to enhance their overall healthcare experience.
Questions? Concerns?
Thank You!
Available exclusively in Apple’s App Store for
iOS phones and tablets
Check out www.patientadvocate.org/webinars for sessions
available with the Patient Empowerment Series.
Built to address the challenges that are
known to frequently occur for Narcolepsy
patients
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